A nurse is observing a new mother bathing her newborn son for the first time. For which of the following actions should the nurse intervene?

Choice a reason:
The pattern of contractions can be a sign of true labor when they are regular, frequent, and increase in intensity and duration over time. In true labor, contractions do not subside with rest or hydration and become progressively more organized. However, contractions alone can be misleading, as Braxton Hicks contractions may also present a pattern but do not lead to cervical changes.

Choice b reason:
The station of the presenting part refers to the position of the baby's head (or presenting part) in relation to the ischial spines of the mother's pelvis. While the station can indicate how far labor has progressed, it is not a definitive sign of true labor. The station changes as labor progresses, but it can also be affected by other factors such as the baby's position.

Choice c reason:
Rupture of the membranes, commonly known as water breaking, can occur before or during labor. While it is a sign that labor may be imminent, it does not confirm true labor. Some women may experience premature rupture of membranes without contractions or cervical changes.

Choice d reason:
Changes in the cervix, including effacement (thinning) and dilation (opening), are the most reliable signs of true labor. Effacement is measured in percentages, and dilation is measured in centimeters. The cervix must be 100% effaced and dilated to 10 centimeters for childbirth to occur. These changes are a direct result of true labor contractions and indicate that the body is preparing for delivery.

Choice A reason:
Continuous fetal monitoring is a standard order for clients with severe preeclampsia. It allows healthcare providers to assess the baby's heart rate pattern, which can indicate how well the baby is tolerating the intrauterine environment. This is particularly important in cases of severe preeclampsia, where there is a risk of fetal distress.

Choice B reason:
Obtaining a daily weight is also a standard practice for clients with severe preeclampsia. Weight gain can be an indicator of worsening preeclampsia due to fluid retention and should be monitored closely. Sudden weight gain can signify increased fluid retention, which may require medical intervention.

Choice C reason:
Assessing deep tendon reflexes every hour is appropriate for clients with severe preeclampsia. Hyperreflexia can be a sign of worsening preeclampsia and impending eclampsia. Frequent monitoring allows for early detection of changes in reflexes, which can be critical in managing the condition.

Choice D reason:
Ambulating twice daily would require clarification because clients with severe preeclampsia are typically advised to have bed rest to lower blood pressure and reduce the risk of complications. Ambulation could increase the risk of hypertensive crisis or other complications, so this order seems contrary to standard management practices for severe preeclampsia.